Otoplasty: surgical correction of lop-eared

The abundance of otoplasty techniques described in the literature makes it a unique phenomenon in its field. Since then, as in 1881, Ely described the technique of correction of lop-eared, more than 200 operations of this kind have appeared. As with all plastic surgeries, the latest studies are dominated by modern conservative and minimalist approaches.

Otoplasty is a surgical correction of the lop-eared. By analogy with rhinoplasty, in this case the path to the optimal result begins with a three-dimensional analysis of deformation. Surgical correction requires the determination of the ratio of the auricle components to the underlying bone skeleton. Moreover, in order to preserve the natural appearance of the ear, these components-the curl-antidotes, the auricle, the tragus-protivo-vkocelok, and the lobe-must be evaluated before surgery, and when it is performed, be set in the natural position for the ear.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Historical essay

Deformations of the auricle for many years have been the subject of creative analysis. Certain signs (for example, Darwin's tubercles and flattened edges of the auricle) were considered as predisposing to criminal behavior. The deformation to which this chapter is devoted, in fact, is a whole group of deformations that have such a common external manifestation as a protruding ear. This may be a consequence of the classic absence of anti-malignancy, excessive protrusion of the auricle or a combination of these deformations. Less often the deformity is aggravated by the presence of a swirling or protruding ear lobe.

Methods to restore the normal relationship of the auricle with the skin of the scalp and the underlying mastoid process have been described since the 19th century. The first description of otoplasty was given by Ely, which reduced the protruding ear by performing a through excision of the ear site, consisting of the skin of the anterior surface, cartilage and skin of the posterior surface. Later, similar techniques were proposed (Haug, Monks, Joseph, Ballenger and Ballenger), which used a reduction approach to otoplasty, that is, removal of the skin and cartilage.

In 1910, Luckett rightly considered the cause of the classic bumpy absence of an anti-wrench fold. This discovery, in the light of the anatomical approach to defect correction, allowed him and the subsequent authors to develop the right approaches. Early techniques included dissection of the ear cartilage in front and behind from the prospective location of the anti-malignancy. Luckett proposed a semilunar excision of the skin and cartilage at the site of the planned antidote. The remaining edges of the cartilage were then sewn together. The Becker technique also included anterior and posterior incisions around the planned countercurrent. Then he formed a new anti-twist with fixing seams. A further change is seen in the Converse technique, where the front and rear incisions were followed by the cross-linking of the anti-twist segment in the form of a tunnel.

The emphasis in modern techniques is to ensure that there are no visible traces of the operation performed. We must strive to ensure that the edges of the cartilage are not visible, and the ear is smooth, attractive, and proportional to the skull. After discussing applied anatomy and embryology, we will distinguish two basic approaches to otoplasty - stitching cartilage and molding cartilage - and many developed variations of both techniques.

Anatomy and embryology

The outer ear is a cartilaginous structure, with the exception of the lobe, which does not contain cartilage. This flexible elastic cartilage is covered with a skin tightly attached from the front and more friable - from behind. The cartilaginous plate has a definite shape and can be described as a combination of crests and voids that do not completely surround the osseous external auditory canal.

The normal ear is located at an angle of 20-30 ° to the skull. The distance from the lateral edge of the curl to the skin of the mastoid process is usually 2-2.5 cm. When viewed from the upper point, it is noticeable that the slope is the result of a combination of a conchocellate angle of 90 ° and a conholadial angle of 90 °. The average length and width of the male ear is 63.5 and 35.5 mm, respectively. The corresponding sizes for women are 59.0 and 32.5 mm.

The analysis of the bends of the normal ear begins with a curl and a counter-cuff. They start from below, at the level of the tragus, and diverge to the top, where they are separated by a navicular fossa. At the top of the countercuts is divided into a smoother, wider upper leg and lower leg. When viewed from the front, the curl forms the most lateral ear deviation from above and should be only slightly visible behind the anti-wrench and upper leg.

The cartilage is attached to the skull by three ligaments. The anterior ligament attaches the curl and the tragus to the zygomatic process of the temporal bone. The anterior part of the cartilaginous external auditory canal is devoid of cartilage and is delimited by a ligament going from the tragus to the curl.

The ear has external and internal muscles innervated by the seventh pair of cranial nerves. These small muscles are concentrated in certain areas, creating soft-tissue thickenings with increased blood flow. These muscles are practically not functioning, although some people can move their ears.

Arterial blood supply to the ear. It is carried out, mainly, from the superficial temporal artery and posterior ear artery, although there are several branches from the deep ear artery. Venous outflow occurs in the superficial temporal and posterior ear veins. Lymph outflow is carried out in the parotid and superficial cervical lymph nodes.

Sensitive innervation of the external ear is provided by several sources. The temporo-auric branch of the mandibular portion of the fifth pair of cranial nerves innervates the leading edge of the curl and part of the tragus. The rest of the anterior ear is innervated mainly by the large ear-nerve, whereas the posterior surface of the ear receives innervation from the small occipital nerve. A small contribution is made by the seventh, ninth and tenth pairs of cranial nerves.

"Knots of the Hyis" are the six visible projections described by this author, developing in the ear of a 39-day-old embryo. Although Guis related the origin of the first three tubercles to the first branchial arch, and three others to the second branchial arch, subsequent studies challenged this theory. Now it is considered that only the tragus can be attributed to the first branchial arch, and the rest of the ear develops from the second branchial arch. This opinion is supported by the fact that congenital parotid fossils and fistulas are located along the anterior and intercostal scissors. Since these areas are anatomically representing the dividing line between the first and second branchial arches, the mentioned anomalies can originate from the first pharyngeal depression. Most deformities of the ear are inherited by an autosomal dominant type. A similar type of inheritance is also observed in parotid pits and appendages.

[11], [12], [13], [14], [15], [16], [17]

Function

The function of the ear in lower animals has been well studied. Two installed functions are the localization of sound and protection against water penetration. Protection against water is provided by contrasting the tragus and the anti-trap. In humans these physiological functions are not confirmed.

Preoperative evaluation

Like all other facial plastic surgeries, otoplasty requires accurate preoperative evaluation and analysis. Each ear needs to be evaluated separately, since the existing deformation or deformations can be very different from different sides. The ear needs to be estimated according to size, the relationship with the scalp and the relationship between its four components (curl, anti-wrench, shell and lobe). Typical measurements recorded during preoperative examination are:

• The distance between the mastoid process and the curl at the level of its upper point.
• The distance between the mastoid process and the curl at the level of the external auditory meatus.
• The distance between the mastoid process and the curl at the level of the lobe.

Additional measurements made by some authors include measuring the distances from the tip of the edge of the curl to the connection of the upper and lower legs, as well as the distance from the edge of the curl to the counter-grip.

Pre-operative photographs are taken - a view of the entire face from the front, a view of the entire head from behind and sighting pictures of the ear (ears) in the position of the head in which the Frankfurt horizontal is parallel to the floor.

The anomaly most often observed in the protruding ear is the proliferation or protrusion of the cartilage of the auricle. Such deformations are not corrected by operations that restore the countercurrent. It requires interventions in the relationship between the auricle and the compact layer of the mastoid process. Bulging of the lobe may be the only deformity in the whole normal ear. This may be a consequence of the unusual shape of the tail of the curl.

Techniques of otoplasty

A typical patient for otoplasty is a child aged 4-5 years who is directed by a pediatrician or parents in connection with ottopryrennostyu ears. This is the ideal age for correction, since the ear is already fully formed, and the child has not yet gone to school, where he can become a subject of ridicule.

In young children, anesthesia is most commonly used. In older children and adults, intravenous sedation is preferable. The head of the patient is placed on the headrest, the ears remain open throughout the operation.

The surgical techniques used to correct the loparound depend on the preoperative analysis. The protrusion of the shell in the form of an isolated deformation or in combination with the deformation of the counter-cracks is often determined.

Shifting the auricle back

Return of the auricle to the correct anatomical position in relation to the mastoid process is performed with the help of seams, with the cutting of the lateral edge of its cavity or without it. The traditional technique of shifting the auricle back, as it was described by Furnas, remains the operation of choice with bulging auricles. This technique is characterized by a broad exposure of the posterior surface of the ear and the periosteum of the mastoid process. Through the cartilage of the auricle, and then through the periosteum of the macular process, constant seams are made of non-absorbable material (the author prefers Mersilene 4-0) in such a way as to fix the auricle in the posterior and medial direction. Do not apply sutures to the periosteum too far anteriorly, otherwise the external auditory can be affected. Additional correction of the protruding anuricle can be achieved by excision of the lateral band of the cartilage of the shell. The incision can be made in the lateral part of the auricle, along the landmarks applied by 25 gauge needles moistened with methylene blue. This cut allows you to remove the elliptical area of the cartilage of the auricle for additional medial displacement of the ear.

An alternative operation on the auricle is described by Spira and Stal. This is the technique of a lateral flap, when a flap with a lateral base is created from the cartilage of the auricle, which is sewn from behind to the periosteum of the mastoid process. Supporters of this method believe that it reduces the probability of deformation of the external auditory canal.

Defect deformation

A number of described operations to recreate the missing countercurrent indicate that there is no complete satisfaction of any of them. With the development of the technique of otoplasty, two schools were distinguished. The first, following the teachings of Mustarde, used to create anti-twist seams. The second group of operations included surgical interventions on the cartilage, by incisions, dermabrasion or corrugation. Most modern techniques are a combination of these two approaches, using seams to fix the final position of the antifloric, but adding methods of modifying the cartilage to reduce the risk of re-bulging.

[18]

Suture technology

For most otoplasty techniques, access and guidelines are similar. A BTE incision is made and a wide incision is made over the perichondria. The area of the proposed counterstick can be marked by injecting needles 25 gauge G from front to back, through the skin and cartilage, which is then marked with methylene blue.

The Mustarde operation consists of applying three or four horizontal seams to create a permanent counter-wax. We consider the most suitable for this purpose Mersilene 4-0, but it is reported and the use of many other suture materials. The technique of suturing is crucial for obtaining a smooth correction and preventing deformation of the upper part of the ear. The suture is performed through the cartilage and the anterior periondrium, but not through the skin of the anterior surface of the ear. If the seam does not seize the anterior perichondrium, there is a risk of wrinkling of the cartilage. If it is placed too far anteriorly, it can grab the inner surface of the anterior ear dermis and cause pulling in the stitching site.

According to Bull and Mustarde, the seams should be superimposed as closely as possible to avoid corrugation. However, if the position of the cartilage is too close, it can be weakened between the seams. In addition, if the outer portion of the seam is too close to the tip of the ear, deformation may occur as a mail envelope. The authors propose to impose centimeter stitches with distances of 2 mm on the distal cartilage. Distance between distal and proximal injections is 16 mm. The lowest seam is superimposed to shift the tail of the curl to the back. In some cases, cropping is performed.

Technical complications of standard otoplasty for Mustarde are related to the accuracy of suturing. Often, the tightening of the seams is done blindly, when the surgeon sets the degree of tension, watching the folding of tissues in the countercurrent from the outside of the ear. All seams should be applied until they are finally tightened. Some authors describe the technique using temporary seams, which are applied from the front to fix the shape of the alleged counter-curl while the back seams are tightened. Burres described an "anteroposterior" technique, according to which the auricle is retracted through the posterior incision, but the seams on the curl are superimposed in front, through a series of anterior incisions. According to another technique, these seams can be applied from the outside, but drown in small incisions. Since Mustarde published his first work, there have been descriptions of a variety of additional procedures aimed at correcting the ear tendencies with time to move forward again. This is due to several factors. Firstly, improper suturing without seizing a sufficient portion of the cartilage leads to the eruption of the filaments and the return of the ear to its original position. Secondly, when the seam does not capture, this perichondrial promotes the eruption of the cartilage. Therefore, one must be especially careful, ensuring their correct application - the most frequent factor of repeated displacement of the ear is the springing rigidity of the cartilage. Therefore, various methods have been proposed to reduce the memory of cartilage shape. According to physiological principles, the presence of cartilage in the desired position should be facilitated by the corrugation of the anterior surface of the ear. Such studies were carried out by Gibson and Davis, who showed that the corrugated costal cartilage curves in the opposite direction. Using the costal cartilage, they demonstrated that if one side of the rib is deprived of perichondria, the cartilage will bend to the side where the perichondria is preserved. When trying to create a new antiflora from a flat area of the ear cartilage, weakening the front surface of the cartilage will cause bending to form a convex front surface. The corrugation of the front surface of the ear cartilage at the site of the new antifloric can be done with a needle, abductor or cutter. Do not be too aggressive in doing this procedure, as sharp edges can form. Access to the front surface of the cartilage can be done from the anterior incision by cutting the tissue around the edge of the curl from the behind-the-back incision or using the technique described by Spira, making the cartilage on the cartilage with a needle inserted through the punching in front. Spira describes its modification of the technique on more than 200 cases of otoplasty with minimal complications.

Ripping the back of the ear is technically easier than with the front, if access has already been made. Physiologically, the cartilage will tend to bend in the opposite direction to that required to create a countercut, but suturing easily prevents it. Pilz et al. Performed more than 300 such otoplastics with excellent results.

Methods of molding cartilage

The methods of molding cartilage are the very first operations on otoplasty. To change the shape of the ear cartilage, they are used most often. If successful, these operations do not require permanent stitching. This reduces the risks associated with the reaction to the foreign body that exist in the operations of Mustarde.

The technique of otoplasty with cleavage of cartilage was first described by Nachlas et al. In 1970. Based on the earlier work of Cloutier, this operation uses the principle of Gibson and Davis to create a new countercurrent. A standard bovine incision is performed, the placement of which is determined after marking the area of the alleged anti-curl with a 25 G needle moistened in methylene blue. Usually an elliptical patch of skin is excised. Sometimes, if the lobe of the ear protrudes, an incision is made in the form of an hourglass. Then the needles are removed. A standard wide preparation behind the ear is performed, exposing the tail of the curl, the scaphoid fossa of the anticancer and the cartilage of the auricle. The Cottle blade cuts through the ear cartilage. It should be done about 5 mm anterior to the marks marking the top of the new counter-wrench. The incision will be curved, parallel to the edge of the curl, and start from a point about 5 mm below the top of the edge of the curl to its tail. Resection of the latter helps to eliminate postoperative bending of the lobe. Perpendicular to the upper and lower edge of the cut, triangular wedges are removed. At this stage, the lateral part of the cartilage is attached to its medial part only along the upper margin. Perichondria is separated from the front surface of the cartilage by a distance of approximately 1 cm. The anterior surface of the medial cartilage is treated with a diamond cutter, until a rounded smooth new anti-curvature and upper leg form. The anterior surface of the lateral cartilage is also treated. The processed medial cartilage is placed in front of the lateral, restoring the normal contour of the ear. Stitches on the cartilage are not superimposed. The skin is stitched with a continuous subcutaneous suture.

In otoplasty with cleavage of the cartilage, the edges of the incision are turned back; in the front part of the ear, only one cartilaginous surface is visible - this is the smooth bulge of the new antiflora. Modification of this technique, described by Schuffencker and Reichert, requires the formation of a large V-shaped cartilaginous flap on the side of the alleged antiserum. Instead of a single curved incision of the cartilage at the site of the new antiserum, the authors distinguish a cartilage flap that is tucked upward. The required convexity is then created by corrugating the front surface with a blade.

In any operation, the choice of the correct technique of otoplasty depends on the experience and skill of the surgeon. For beginner surgeons, the simplest is the Mustarde technique. Reducing the back surface of the cartilage with a diamond cutter slightly complicates the procedure, but significantly reduces the likelihood of relapse. In more complex cases, more predictable results, in the hands of the author, in the absence of complications associated with Mustarde sutures, give otoplasty with the splitting of cartilage.

Regardless of the otoplasty technique used, an appropriate bandage is required to preserve the position of the ear without undesirable exercise. To prevent swelling in the furrows of the ear, mineral wool soaked in mineral oil is laid. Usually the dressing consists of a powder and a Kerlex coating, and the top is sealed with a Coban patch. It is recommended to use drains. The ears are inspected on the first day after the operation. The patient is asked to bring a tennis ribbon to his hair for the first bandage. She is superimposed by the surgeon after removing the bandages and left in place until the stitches are removed, for 1 week. To prevent accidental injury to the ears within 2 months after the operation, the patient is recommended to wear an elastic band for the hair at night.

Results

Otoplasty, in general, is an operation that brings satisfaction to both the surgeon and the patient. Achievement of symmetry and the creation of ears with smooth curls and furrows are undoubted advantages of otoplasty. Since similar results can be achieved with a number of operations, the choice of technique, which gives fewer complications and better long-term results, is becoming increasingly important. Many authors get satisfactory results using a wide range of techniques, so the choice of a particular technique is not as crucial as the ownership of its technique.

Complications

[19], [20], [21], [22], [23], [24]

Early complications

The most disturbing complications of otoplasty are hematoma and infection. Excessive pressure exerted on the ear cartilage by hematoma can lead to necrosis of the cartilage. Infection can cause perichondritis and purulent chondritis with the outcome of necrosis and deformation of the ear cartilage. The incidence of hematomas is approximately 1%. Schuffenecker and Reichert after performing 3,200 cartilage shaping operations reported two cases of hematoma.

Prevention of hematoma formation begins with a thorough preoperative assessment of the tendency to bleeding and traumatism. In the absence of haemostasis in a family history, laboratory examination of the haemostatic profile is usually not performed. In the operation, bipolar coagulation is used to prevent necrosis of the cartilage. In cases of bilateral otoplasty in the ear, which was operated in the first place, impregnated cotton bandage is applied. After completion of otoplasty on the opposite side, the first ear should be inspected for hemostasis and no hematoma. A small drainage rubber strip is left in the bovine furrow, which should be in a section before the first dressing.

Unilateral pain is the earliest sign of the development of a hematoma. In general, patients after otoplasty for the first 48 hours feel minimal discomfort. Any discomfort should be an excuse for removing the bandage and examining the wound. The presence of a hematoma requires the opening of a wound, stopping bleeding, washing with an antibiotic solution and re-applying the bandage.

Wound infection usually appears on the 3-4th day after surgery. The reddening of the edges of the wound and the puffy discharge can be observed in the absence of significant pain. Wound infection should be treated intensively, without waiting for the development of perichondritis or chondritis. In these cases, systemic antibiotic therapy is required, effective even against Pseudomonas aeruginosa. Purulent chondritis is rare, but it is a serious complication when the infection penetrates into the cartilage, causing necrosis and resorption. A harbinger of its development is a deep gnawing pain. The results of the examination are often inexpressive compared to the symptomatology. The diagnosis is made after the failure of conservative treatment of the infection. Principles of treatment consist in systemic antibiotic therapy, surgical treatment and drainage. Usually, repeated economical surgical treatments are required. The resolution of the infection is characterized by a reduction in pain and an improvement in the appearance of the wound. The long-term effects of chondrite can be devastating. Necrosis of cartilage leads to permanent deformation of the ear.

[25], [26], [27], [28], [29], [30]

Late complications

The late complications of otoplasty include suturing and aesthetic problems. Segmentation of the joints after operations Mustarde occurs not so seldom and can occur at any stage of the postoperative period. It can be the result of improper suturing, excessive strain of the ear cartilage or infection. Treatment consists in removing unsuccessful sutures. Early suturing requires a surgical revision to restore the correction. In the case of late eruption, revision may not be necessary if the ear remains in the correct form.

To aesthetic complications include the wrong relationship between the ear and the scalp, as well as the skew of the ear itself. The last complication includes inadequate correction of the ears, its relapse and excessive correction. The skew of the ear can manifest itself in the form of telephone deformation, reverse phone deformation, ear warpage, ear pulling, and underlining the edges of the cartilage.

Inadequate correction may result from improper diagnosis. Ears, the main deformation of which consists in the protrusion of the shell, can not be corrected in ways designed to reconstruct the antiflora. The accuracy of preoperative and intraoperative measurements is the determining factor for achieving the desired degree of correction. Other possible factors include cutting and weakening of the joints. Some of the protrusions associated with the memory of the shape of the cartilage are noted in most cases of plastic surgery, carried out exclusively with the help of seams. There is a report about the presence of some degree of re-prosthesis in all cases, especially noticeable in the upper pole. Excessive correction of the protruding ear can lead to pressing the ear to the scalp. Often this is more unpleasant for the surgeon than for the patient, but, nevertheless, this can be prevented by careful pre-operative measurements.

Phone deformation of the ear is an unnatural result, when in the middle third of the ear a hypercorrection is created in comparison with the upper and lower poles. This is often observed after an aggressive shift of the auricle back with insufficient correction of the upper pole. Phone deformation can also be associated with the uncorrected, protruding tail of the curl. An inverse telephone deformation occurs when the middle part of the ear protrudes with an adequate or excessive correction of the upper pole and the lobe. This may be a consequence of the insufficient correction of the projecting shell. Secondary correction of any of these deformities can lead to excessive ear adhesion.

Scarification of the ear cartilage is observed when using seam techniques, when the seams are superimposed too far apart. This can be avoided by applying the intervals recommended for these methods.

Nasal Bars can have different severity, from cord-like, along the seams, to keloid. Cord lobes are observed only after suture otoplasty, when, as a result of excessive tension of the threads, their skin wraps around them. This leads to the formation of unsightly BTE scars. In any technique of otoplasty, when the bovine incision is sutured with excessive tension, rumen hypertrophy may be observed. Keloid formation occurs rarely (more often in black patients). In a large series of studies, the frequency of postoperative keloid formation was 2.3%. First, they are conservatively treated with injections of triamcinolone acetonide (10, 20 or 40 mg / ml) every 2-3 weeks. The mechanism of action of steroids is to reduce the synthesis of collagen and increase its decay. If surgical excision is required, it is performed sparingly, using a carbon dioxide laser. Some authors recommend leaving a keloid strip to prevent further stimulation of keloid tissue production. In the postoperative period, injections of steroids are used, which in women can be combined with the application of therapeutic clips. It is also reported about the successful treatment of recurrent keloids with small doses of radioactive irradiation.